RL Datix is the platform that we use to capture any adverse events across all campuses. This is a voluntary reporting system on the UTMB home page for employees to access and report events.
In March, there were 726 events; April had 610 events reported using the RL Datix system. The RL Datix system is a robust reporting tool that allows us to drill down into each event as well as by event category as they are reported.
Once a report is filed, within a few minutes to hours it is “tasked” (an email is sent to the individuals assigned to review) to the manager of the unit/department where it was reported to have happened, as well as to several staff within the Quality & Patient Safety. The staff in Q&PS review these daily, Monday through Friday. The Q&PS staff identify a harm score for each event, ranging from 0 to 9. Zero is “no harm to patient” with nine being “harm to patient that may have caused serious injury or death.”
The managers/supervisors and others assigned for each area review the events for their individual areas and investigate. They often will review the medical record and speak to those involved with the care of the patient depending on the severity of the event. We encourage managers to share some of the events at their routine staff meetings with short discussions of what actions might be taken to eliminate such future events. Of course, any events that surround a behavioral issue will only be shared with the individuals involved—the actions are never shared with all in that area.
Some examples of the events reported in April and how the events are analyzed include looking at how long it takes to complete a RL Datix event on average. This has dropped to ≈10.3 minutes from 14.55 minutes when we first started using RL Datix. We are always looking at ways to streamline the process to be more efficient, as we know the time it takes to report the event takes away from your time at the bedside or the time you can leave at the end of your shift.
We evaluate the severity level assigned to the events and which scores are assigned most frequently. The scores from 0 to 4 indicate no harm to the patient. Routine reports shared with leadership monthly also includes the top 5 event types reported for each month. In March these included events categorized as Blood Products, Provision of Care, Falls, Diagnosis/Treatment and Medication/Fluids. These then are broken out by the top five events in each of these categories for review. As mentioned in last month’s newsletter, we shared information related to the increased numbers of Workplace Violence events.
We will share more information monthly about the Top Five events in subsequent reports.
—Submitted by Ladonna Strait, director, Quality Management & Patient Safety